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Artificial Nutrition and Hydration 20-130907 Back to Course Index

Artificial Nutrition and Hydration

AHN1

 

Introduction:

 

If a patient is unable to swallow due to a medical problem or other restrictions, he or she may be given fluids and nutrition by the administration of artificial nutrition and hydration (ANH). This is sometimes done when a patient is recovering from an illness or injury when someone has an advanced, life-threatening illness.  ANH may also be administered during hospice or palliative cases.   

 

Artificial nutrition and hydration are a balanced mix of nutrients and fluids and are applied through a tube fed directly into the stomach, the intestine, or a vein. It is a medical treatment that allows doctors to overcome whatever may be preventing a person from eating or drinking. During an illness, a patient often loses the ability to receive nutrition or hydration by natural means. When a patient can no longer receive food and fluids normally, artificial nutrition or hydration can benefit the patient by helping the patient to maintain proper nutrition and fluid balance. Since inadequate nutrition and hydration can lead to deterioration of health and may result in death, artificial nutrition and hydration can be viewed as key elements in sustaining life.

 

Short-term artificial nutrition and hydration are often given to patients recovering from surgery to greatly improve the healing process. It may also be given to patients with increased nutritional requirements or to someone who cannot swallow because of an obstructing tumor.

 

A highly sophisticated form of artificial nutrition and hydration called Total Parenteral Nutrition (TPN) can be given indefinitely. TPN can be administered to patients with serious intestinal disorders that impair their ability to digest food, enabling them to live fairly normal lives. Also, long-term artificial nutrition and hydration are commonly given to people with neurological disorders.

       

In this course, we will explore this treatment in some detail, along with different views, its advantages and disadvantages, and in particular, how it relates to the controversial subject of Euthanasia.

 

Administering Artificial Nutrition and Hydration

 

Artificial nutrition and hydration can be administered in several ways. An intravenous (IV) catheter (a thin plastic tube that slides in over a needle) may be placed in the vein under the patient’s skin. Fluids and sometimes nutrition is given through the catheter.  Hydration alone can be provided by subcutaneous infusion.

 

Usually, artificial nutrition is provided through a flexible tube inserted through the nasal passage down the throat, it is called the NasoGastric or NG tube, through the wall of the abdomen and into the stomach. It can only be left in for a short time, usually 1 to 4 weeks. This procedure is called a gastrostomy. 

 

If the tube has to be in longer, a different kind of feeding tube may be used. It’s placed into the wall of the stomach, G tube, or PEG, or into the intestine through a procedure called a jejunostomy.

 

TPN requires the surgical insertion of a special port, usually into a vein below the collarbone. Fluid with limited amounts of nutrients can be supplied directly into a vein in the arm through the Intra Venous (IV) line.

       

Nutrition and hydration through artificial means can be supplied temporarily, as noted, or indefinitely depending on the patient’s condition. If artificial nutrition is likely to be given for a long time, a surgically implanted tube is considered more comfortable for the patient and has fewer side effects.

 

Medical and Ethical Views Regarding ANH

 

The most common legal view of ANH is that it is a medical treatment. But many professionals and laypersons view it otherwise. For example, the NYS Proxy Law does not automatically grant permission to a relative or caregiver of an incapacitated patient to forgo ANH, but it does if the relative or caregiver is reasonably familiar with the patient’s view of ANH. Courts in New Jersey and Massachusetts, at times, allow the withdrawal of ANH from patients in a permanent vegetative state at the request of family members. In Missouri, the state courts rejected the family testimony as evidence sufficient to prove the wishes of the incapacitated person. (ORourke 1990)  One of the most recent and unarguably largest legal battles over the discontinuance of ANH was the Terri Schiavo case in Florida.  Ms. Schiavo collapsed from heart failure which resulted in severe brain damage.  Approximately eight years after her heart failure, Schiavo’s husband and her parents began a legal tug-of-war over whether to have her feeding tube removed and allow her to die. The case drew national attention and rallied activists on both sides of the right-to-die debate.  Terri Schiavo’s husband, parents, the courts, and members of Congress waded into the battle over the woman’s fate.   On March 31st of 2005, the 41-year-old woman who became the centerpiece of a national right-to-die battle, died nearly two weeks after doctors removed the feeding tube that had sustained her for more than a decade.

 

If one believes ANH is a medical treatment, then any decision about its use is made by weighing the burdens and benefits of the treatment. That means it is treated as a part of the medical treatment plan, which is aimed at achieving defined goals of medical care determined from the patient’s perspective. The patient’s values and attitudes dictate legitimate goals of treatment.

 

On the other hand, if ANH is not considered a medical treatment, then decisions about its use are much simpler. If the patient is not eating and drinking, ANH is mandatory in all cases, irrespective of patient wishes, goals of treatment, the likelihood of improvement, or the burden of its administration.

 

Religious Point of View

 

An issue such as ANH can often crystallize as a fundamental moral issue rather than a medical one.  Most religions indicate that humans are created in the image of God, and they have a god-given duty of life preservation. This duty falls on the shoulders of even terminally ill patients, and many believe that all conceivable means should be employed to preserve and save a life even if it involves the use of artificial means such as nutrition and hydration.  In most religions, suicide and murder are sins.  The view that life is a gift from God and should not be destroyed is widely held.  The Christian faith explicitly condemns Euthanasia.  On the other hand, some religions teach the refusal of all medical treatments. 

 

These religious views will be discussed again, relating to Euthanasia.

 

Euthanasia

 

Persons who don’t receive any food or fluids will eventually fall into a deep sleep (coma) and usually die in 1 to 3 weeks.  In the case of an individual who is in a permanent vegetative state and removed from ANH, the cause of death is noted as what caused the state to begin with or the failure of the necessary bodily function.  However, the knowledge that continuing ANH in some cases will prolong life for up to a decade or more and that removing it will result in death within weeks leads to the deduction that removing ANH in these cases is the assurance of death.

 

Euthanasia is the practice of ending a person’s life for the sole purpose of relieving the person’s body from excruciating pain and suffering due to an incurable disease. The term euthanasia is often referred to as mercy killing or the good death as derived from the Greek. Euthanasia can be classified into four categories. Inactive Euthanasia, a person”s life is terminated by a doctor through a lethal dose of medication. Passive Euthanasia implies the non-provision of life-sustaining treatment to a patient based on logical reasoning or, in other words doing nothing to save a person’s life by abstaining from giving life-saving measures like putting a person on an artificial respirator.  The way of distinguishing active and passive forms of Euthanasia is a mere difference between act and omission. The other forms include voluntary and non-voluntary Euthanasia. Involuntary Euthanasia, a patient’s consent is obtained for either active or passive Euthanasia, whereas non-voluntary Euthanasia refers to ending a patient’s life without his/her consent (Rachels, 1975).

       

Euthanasia had been initially accepted in history. Greece and the Romans permitted it in certain circumstances (Beauchamp, 2005). However, with the arrival of religions like Judaism, Christianity, and Islam, the practice of Euthanasia was morally and ethically rejected. Life was regarded as a gift from God, and no situation permitted its annihilation. The laws of modern societies followed the general principles of these religions. It was only in the last century that active debates on Euthanasia commenced authenticating its legality and ethical righteousness.  

 

Proponents of the issue started advocating the option of life and death as the sole right of a human being. Alexander Capron, a renowned American lawyer, propagated the concept by stating, “I never want to wonder whether the physician coming into my hospital room is wearing the white coat of the healer or the black hood of the executioner.” Opponents, however, strongly reject the idea of highlighting its serious ramifications. The majority of people opposing the issue are overshadowed by religious ethos. In 1995, Pope John Paul II strongly opposed the idea by saying Euthanasia is a grave violation of the law of God since it is the deliberate and morally unacceptable killing of a human person. In 1999, Pope John Paul II again spoke out against death at the hands of doctors (Sabelko, 1999).

       

Still, to date, most countries of the world, including the United States, retain restrictions on some forms of Euthanasia. The debate, however, continues unabated. The issue is intricate and thought-provoking. If taking a person’s life suffering from unbearable pain is unethical, then keeping the same person alive is inhumane. Both sides have strong arguments. This essay will scrutinize the arguments of both sides while focusing on the negative effects of legalizing active Euthanasia. Various aspects related to the issue encompassing the viewpoint of both sides are covered in subsequent paragraphs.

 

Mitigation of suffering through the purposeful destruction of the life of the sufferer is contrary to the religious concept of respect for life. It is said that in the Netherlands, as many as one-sixth of all deaths are attributable to Euthanasia. In 1986 the Council of Ethical and Judicial Affairs of the American Medical Association stated that “it is not unethical to discontinue all means of life-prolonging medical treatment” for patients in irreversible comas.

A patient in a persistent vegetative state is not in a terminal condition since nutrition and hydration, and ordinary care will allow him to live for years. It is only if that care is taken away that the patient will die. So it is the removal of the nutrition and hydration that brings about death. This is Euthanasia by omission rather than by positive lethal action. It is morally wrong to take these extreme cases and make them the norm for all cases of persistent vegetative state patients when treatment allows that patient to continue to live without the burden of excessive pain or suffering. In such cases, their removal is equivalent to passive Euthanasia i.e., killing by omission.

 

The view held by some that are concerned that withholding or withdrawing artificial nutrition or hydration is the same thing as starving a patient to death, thereby murdering the patient, can be argued against from the perspective of the cause of death.  As noted earlier, when a dying patient (or his or her surrogate decision-maker) decides to forego artificial nutrition or hydration, the patient’s disease is the cause of death. From a medical perspective, withholding or withdrawing artificial nutrition or hydration from a dying patient is no different from the decision to forego any other medical treatment, such as artificial ventilation, which may prolong the process.

 

Advantages

 

Although there are recent studies that suggest as a person is dying, the body loses its desire for nutrients.  A person with a temporary illness who can’t swallow may be hungry and thirsty. A feeding tube may help.

 

Sometimes a person may become confused because of dehydration. Giving a patient fluids through a tube will decrease dehydration and may lessen his or her confusion and discomfort. Giving fluids and nutrition helps the patient as he or she is recovering.

 

For a patient with an advanced life-threatening illness who is dying, artificial hydration and nutrition may make the patient live a little longer, but not always. (American Family Physician 2000)

 

ANH may improve survival among patients in a permanent vegetative state, sustaining them for ten or more years when they would die within weeks without ANH support. 

 

Parenteral ANH can also prolong the lives of patients with the extreme short-bowel syndrome (N England Journal of Medicine 1994), and tube feeding can improve the survival and quality of life of patients with amyotrophic lateral sclerosis. (Miller RG, 2001)

 

The opposition to the withdrawal of ANH is done because ANH is necessary to preserve patient dignity. Nutrition and hydration is an ordinary humane treatments and should be provided to every patient. Again visiting the view that withdrawal of ANH amounts to starving the patient to death. Food and water symbolize basic human care for the dying. If we begin withholding such care from the dying, we deny their humanity. (Cranston 2001)

       

Disadvantages

 

Many people who have had a great deal of experience caring for the dying have noted that patients who are not tube-fed seem more comfortable than those who are. Caregivers also observed that symptoms such as nausea, vomiting, abdominal pain, congestion, and shortness of breath decreased when artificial nutrition and hydration were discontinued. For example, patients with pneumonia will not suffer as much from coughing or shortness of breath if they are not receiving fluids. Medical observation has found no indication that patients who have suffered massive brain damage causing permanent unconsciousness experience any pain when artificial nutrition and hydration are stopped. Reports from conscious dying patients indicate that they increasingly experience a lack of appetite and thirst. A dry mouth is the only commonly reported symptom, and this can be managed in many cases without resorting to tubes.

       

Animal studies indicate that the body responds to the lack of food by increasing the production of natural pain relievers. However, if food is supplied, the body stops producing endorphins, and the benefit of this natural pain relief is lost. Historically, a coma has been viewed by some as nature’s way of relieving the suffering of dying. However, the provision of artificial nutrition and hydration may prevent the development of this natural anesthesia in some cases. (Partnership for Caring 2006)

 

There’s also a risk of liquid entering the lungs when someone is fed through a tube. This can cause coughing and pneumonia. Feeding tubes may feel uncomfortable. They can become plugged up, causing pain, nausea, and vomiting.

 

Also, the tubes can damage and erode the lining of the nasal passage, esophagus, stomach, or intestine. If tube placement requires surgery, complications like infection or bleeding may arise. Intravenous lines can become uncomfortable if the insertion site becomes infected. If fluid leaks into the skin, it may cause inflammation or infection.

 

Many patients receiving artificial nutrition and hydration by NG or G-tube have a brain disease and are unable to report that they feel full or unwell, so abdominal bloating, cramps, or diarrhea may occur.

 

With careful attention from healthcare providers, many side effects can be avoided or managed fairly well. However, confused patients also can become anxious over a tube’s presence and try to pull it out. This often leads to the use of restraints or to sedation, which can have a serious effect on a patient’s mental state and their ability to interact or to perform the small activities they might be capable of, such as changing position in bed.

 

The normal intake of food and fluids can also provide the patient with many psychological benefits, such as pleasure, satisfaction, comfort, and a sense of dignity and control. However, since artificial nutrition and hydration bypass the normal method of receiving food and fluids, it may not provide the patient with any of these psychological benefits. ANH can sometimes threaten the patient’s sense of dignity and control. (Medical Ethics Committee 2006)

 

Conclusion

       

Euthanasia remains much debated. Passive forms of Euthanasia have been accepted by many societies, but issues about the legality of active Euthanasia remain contradictory. People favoring the proposal generally advocate the right of self-determination and the principle of mercy as the major driving forces toward deciding on Euthanasia. Whereas, the other school of thought rejects the idea of autonomy since, according to them, a person undergoing serious physical and mental stress is not competent enough to decide about his/her life or death. Moreover, different surveys reveal that less than one-third of the people favoring Euthanasia reasoned their support as ending the pain or incurable disease. The majority of the reasons were psychological.

       

Some people regard the removal of artificial nutrition and hydration as a means to ease the suffering of the terminally and permanently ill, while some people consider it a religious obligation of all humans to preserve and protect life, along with the fact that the prolonging of life with excessive pain and suffering is not only religious but ethical duty. Giving ANH leaves the possibility for the terminally ill to beat the odds and recover by the sheer force of will and fate. Hence, some hold the view that it is better to preserve life in the hope of such an unexplainable occurrence as long as it does not become a burden for the suffering individual.

 

Food and fluids have a great deal of cultural and symbolic value. People associate food and fluids with love and care: feeding a person is often equated with caring for that person. However, when artificial nutrition and hydration are viewed as medical treatments, they have no necessary connection to nurturing. Patients who are not receiving artificial nutrition or hydration may still be provided with adequate care. The medical and nursing staff can still provide a great deal of palliative care for the dying patient that does not involve the administration of artificial nutrition and hydration. The normal intake of food and fluids can also provide the patient with many psychological benefits, such as pleasure, satisfaction, comfort, and a sense of dignity and control. However, since artificial nutrition and hydration bypass the normal method of receiving food and fluids, they may not provide the patient with any of these psychological benefits. Indeed, artificial nutrition and hydration can sometimes have the opposite effect, especially when these medical treatments threaten the patient’s sense of dignity and control.

 

In many states, advanced directives and living wills must specifically mention the desire for not refusal of ANH and are not implied through other stated wishes.  Without such designation in advance, the patient and his or her family should talk with the doctor about the patient’s medical condition and the risks and benefits of giving artificial hydration and nutrition.

 

 

References

 

Artificial Hydration and Nutrition. (2000). Retrieved September 15, 2006, from http://familydoctor.org/629.xml

Beauchamp, Tom, L. (2005). Euthanasia. Microsoft Encarta Online Encyclopedia. Retrieved September 16, 2006 from

http://encarta.msn.com/encyclopedia_761562836/Euthanasia.html

Some Facts About Artificial Nutrition and Hydration. (n.d). Retrieved September 15, 2006, from http://endoflifecare.tripod.com/Caregiving/id90.html

 

Cranston, R. E. (2001). Withholding or Withdrawing of Artificial Nutrition and Hydration. Retrieved September 15, 2006, from http://www.cbhd.org/resources/endoflife/cranston_2001-11-19.htm

 

ORourke, K. (1990). Use of Artificial Hydration and Nutrition: The Clouds are Lifting. Retrieved September 16, 2006, from http://www.op.org/DomCentral/study/kor/90061110.htm

 

Medical Ethics Committee- Statement on Artificial Nutrition. (2006). Retrieved September 16, 2006, from http://www.ecu.edu/cs-dhs/bioethics/artificialnutrition.cfm

 

Questions and Answers: Artificial Nutrition and Hydration and End-of-Life Decision Making. (2006). Retrieved September 16, 2006, from http://www.webmd.com/content/pages/23/110914.htm

 

 Rachels, James. (1975). Active and Passive Euthanasia. The New England Journal of Medicine. Retrieved on September 17, 2006, from

http://www2.sunysuffolk.edu/pecorip/SCCCWEB/ETEXTS/DeathandDying_TEXT/Rachels_Active_Passive.htm

 

Sabelko, Katherine. (1999). Doctors of Life or Death? Newsletter, Children of the Rosary. Retrieved September 17, 2006, from http://www.childrenoftherosary.org/nl1099b.htm#DOCTORS

 

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